After the 2016 Balkan route border closures, vaccination of refugee children in Greece was mainly performed by non-governmental organisations. Activities varied between camps, resulting in heterogeneity of vaccination coverage (VC).

In April 2017, the European programme ‘PHILOS - Emergency health response to refugee crisis’ took over vaccination coordination. Interventions were planned for the first time for refugee children in the community and unaccompanied minors at safe zones. From April 2017–April 2018, 57,615 vaccinations were performed against measles-mumps-rubella (MMR) (21,031), diphtheria-tetanus-pertussis (7,341), poliomyelitis (7,652), pneumococcal disease (5,938), Haemophilus influenzae type b (7,179) and hepatitis B (8,474).

In April 2018, the vaccination status of children at camps (reception and identification centres and community facilities such as hostels/hotels were excluded) was recorded and VC for each disease, stratified by dose, nationality and camp size, was calculated.

More than 80% of the children received the first MMR dose, with VC dropping to 45% for the second dose. For all other vaccines, VC was < 50% for the first dose in children aged 0–4 years and < 25% for the second dose. Despite challenges, PHILOS improved planning and monitoring of vaccination activities; however, further efforts towards improving VC in refugee children are needed.

June 27, 2019

Vaccines are one of the most successful medical measures that save millions of human lives every year. With the implementation of routine immunisation programs, high and maintained vaccination coverages for many vaccine-preventable diseases—such as those against poliomyelitis or diphtheria—have been reached in most European countries and many others. Although vaccine acceptance is often high within the general population, even in countries with high vaccination coverage a significant number of children and adults are not sufficiently vaccinated because of missed opportunities or various concerns and misperceptions.

The reasons for this ‘vaccine hesitancy’ are multifactorial, complex and vary across vaccines, time and countries/regions, and are influenced by factors such as complacency (not perceiving disease as high risk and vaccination as necessary), convenience and constraints (practical barriers), and confidence (lack of trust in safety and effectiveness). As a result, vaccination coverages against highly contagious pathogens such as measles virus are not sufficient to prevent outbreaks and infectious disease spread in many countries today.

Despite the World Health Organization (WHO)’s goal to eliminate measles, a constant increase in measles cases has occurred in recent years. In 2018, more than 82,500 people in 47 of the 53 countries in the WHO European Region were infected with measles, leading to 72 deaths. These numbers were the highest in a decade. They were three times higher than in 2017 and 15 times higher than in 2016, when numbers were at a record low.

In 2019, the situation seems to be even worse, indicating that current plans of action in the affected areas are insufficient to stop measles circulation. This is evidenced by the fact that the estimated coverage with the second dose of a measles-containing vaccine is far below the necessary 95% to achieve herd/population immunity in several European countries.

In order to maintain or improve the population immunity acquired by vaccination, several countries are currently revisiting their strategies and discussing changes in vaccination policies, with a focus on either educating the population and giving individuals freedom of choice or implementing mandatory vaccination to ensure high coverage rates.

With increasing calls to introduce mandatory vaccination programs, intense debates on their effectiveness have also started in several European countries. There are concerns that mandatory vaccination may lead to opposing attitudes and even less vaccine uptake, particularly in those with existing critical attitudes towards vaccines; nonetheless, other studies have disproved that implementation of compulsory vaccination led to opposing attitudes and/or had negative effects.

However, it is indisputable that with any changes in vaccination policies, intensified information strategies are necessary to improve trust, rectify perceived risks and improve access and affordability of vaccines. Moreover, it is important to note that mandatory vaccination can follow different routes depending on a country’s specific social and cultural backgrounds, as well as epidemiological situations.

Consideration of these factors can lead to implementing temporary or permanent vaccine mandates for certain vaccines (such as measles/measles-mumps-rubella (MMR) partial compulsory vaccination), for all vaccines included in a national vaccination program or for selected target groups, such as infants and children before entrance in educational settings or certain occupational groups, such as healthcare workers (HCW).

For example, in France three mandatory vaccines (against diphtheria, tetanus and poliomyelitis (DTP)) co-existed with eight recommended vaccines (against MMR, pertussis, Streptococcus pneumoniae, hepatitis B (HepB), Neisseria meningiditis serogroup C (MenC) and Haemophilus influenza (Hib)) for routine childhood immunisation up until 2017. However, misperceptions in the population, i.e. that non-mandatory vaccines are less valuable, optional or not as safe and effective as the mandatory ones, resulted in insufficient and stagnating vaccine coverages of the recommended vaccines. This growing vaccine hesitancy, as well as large outbreaks and deaths from measles, led to a change in French policy to extend the mandates to all 11 childhood vaccines.

Italy has had a similar situation, where four mandatory vaccines were in place already before 2017 (against poliomyelitis, tetanus, diphtheria and HepB). The coverage for vaccination against measles, mumps and rubella dropped country-wide from 90% to 87% between 2000–16. This, together with large measles outbreaks, led the government to extend the existing vaccine mandates to 10 mandatory vaccines (hexavalent vaccine against DTPert (pertussis)-poliomyelitis-Hib-HepB, as well as MMR and Varicella (V) vaccine) in 2017, whereas vaccination against Men C, S. pneumoniae and rotavirus remained recommended vaccines.

The current issue of Eurosurveillance presents articles from France and Italy on approaches and experiences after the extension of mandatory vaccination. While an article in last week’s issue of Eurosurveillance by Mathieu et al describes the population’s general attitude towards mandatory vaccination shortly before implementation of extended vaccination mandates in France, the rapid communication by Lévy-Bruhl et al. in this issue evaluates the effects of mandatory vaccination on vaccine coverage 2 years after its implementation. D’Ancona et al., also in this issue, depict challenges in Italy in the year following the introduction of the new mandate and how these are being addressed.

June 07, 2019

The New Brunswick government introduced legislative amendments Friday that would make medical exemptions the only acceptable reason for children in public schools and licensed early learning and child care centres not to be immunized.

Under the proposed changes, starting Sept. 21, 2021, all existing and new students would have to either provide proof they're immunized against various diseases, such as measles and whooping cough, or provide a medical exemption form signed by a health-care professional.

If they don't, they won't be allowed in and will have to go to private school or be home-schooled instead, said Dominic Cardy, minister of education and early childhood development.

"It's about protecting our kids, accepting science and evidence, and that's the reason why we're making these changes," he said.

The amendments to the Education Act and the Public Health Act come amid a measles outbreak in the Saint John health region, where 12 cases of the highly contagious respiratory disease have been confirmed, and a whooping cough outbreak in the Fredericton health region, with 28 cases now confirmed.

"Right now, there's a very broad exemption that allows for basically anyone who just says they don't wish to have their children vaccinated," said Cardy.

But there are some children who can't be vaccinated for health reasons, such as being immunocompromised, he said.

The amendments would remove all non-medical exemptions and help protect those vulnerable children through so-called herd immunity, or community immunity, by ensuring at least 95 per cent of students are vaccinated.

The government also plans to look into making immunization mandatory for teachers, bus drivers and other staff, said Cardy, but that will require discussions with unions.

November 13, 2018

PORT MORESBY, Papua New Guinea — Polio was vanquished by the Pacific nation of Papua New Guinea 18 years ago. Now, as world leaders gather there for the Asia-Pacific Economic Cooperation summit meeting this week, polio has returned — on top of raging drug-resistant epidemics of tuberculosis, malaria and H.I.V., and deadly flash points of preventable diseases like whooping cough and measles.

All over the country, there are symptoms of a profound public health emergency; young and old are getting sick and dying unnecessarily, while facilities lack basic medicines and equipment.

Doctors and experts say the unfolding crisis is the realization of their worst fears after years of deterioration and neglect.

“We were expecting something like this,” Dr. Anup Gurung, a public health specialist with the World Health Organization, said of the polio outbreak at a news conference in the capital, Port Moresby, in September.

He pointed to the erosion of vaccination rates, which are down to 30 percent in some parts of the country. “It’s like someone lit a paper castle where everything is on fire,” he said.

Officials in Papua New Guinea hope that hosting the Asia-Pacific Economic Cooperation, or APEC, meeting in Port Moresby will elevate the country’s international profile, but the health crisis has become an embarrassment for a nation with an abundance of gold, copper, silver, oil and gas.

Public frustration with the summit spending has already led to two national strikes. The collapse of health services has been a focus of the protests.

The return of polio is a clear indicator of the failures, with Papua New Guinea accounting for 21 of 109 cases found globally this year.

The Papua New Guinea outbreak is vaccine-derived, which means that weakened live virus excreted by vaccinated children has mutated and escaped into the rapidly increasing unprotected population. Dr. Gurung blamed “the steady breakdown of the health system” for the country’s polio emergency.

Local and international experts point to three interlinked causes of the country’s health crisis: the collapse of the medical supply chain; changing relations with the country’s biggest aid donor, Australia; and rampant corruption.

Getting medicines, equipment and other supplies around Papua New Guinea has always been challenging. The country has few roads, formidable geography and a widely dispersed population, with about 80 percent living in rural and remote locations.

That improved with assistance from Australia, but the Australian government withdrew from the arrangement in protest in 2013 after Papua New Guinea awarded the national medicine supply contract to a local company that Julie Bishop, then the Australian foreign minister, said had no accreditation and “a history of supplying substandard drugs.”

The company, Borneo Pacific, won the contract — worth 32 million Australian dollars, or $23 million — despite its bid being millions of dollars higher than those of reputable international organizations. At the time, the Medical Society of Papua New Guinea said the deal would “lead to the deaths of many Papua New Guineans.”

Reports from health facilities across the country indicate those fears have been borne out. (Borneo Pacific did not respond to requests for comment.)

Heads of educational institutions must already consider affiliating their schools with health facilities for monitoring the health of learners. This is an interpellation of Dr. MUNDAMA WITENDE Jean Paul expressed last Friday during the sensitization session of education executives on the Ebola virus disease.

This provincial health officer in Butembo regrets that school officials do not seem to care about the health of their learners. For him, health professionals will have to regularly examine learners.

"When a school has less than 600 students, it is necessary to have a contract with a hospital that must visit each child at least once a year. But I know that children will come out without having visited. However, during schooling, one must know the growth of the child, see if the child listens well, examine if the child sees well because a child can fail because he does not see, but neither the child's teacher, nor the parent know it. A medical visit must do it. But, we do not do it. And when a school has 600 students, it has permission to operate an infirmary," said Dr. Mundama.

In addition, this health specialist lamented the absence of isolation rooms in most health facilities in the square. For Dr. MUNDAMA WITENDE Jean-Paul, the promoters of these structures must already think about the construction of such a framework.

"Something wrong is good. On the occasion of this disease, I discovered that our hospitals lack hygiene, cases are piled up like sardines on top of each other, first unfortunate finding. The second observation is that several pestilential diseases such as measles and pertussis have disappeared. So there is no isolation structure in our hospitals. So from this illness, we have to recreate isolation services because we can have a case, but we do not know how to isolate it," said this health worker.

Dr. MUNDAMA WITENDE Jean-Paul also called on people to take health as their first concern.

July 25, 2018

On Sunday, Mo Li, 27, was browsing Weibo when she saw the news: 250,000 defective vaccines had been administered to children in the province where she and her husband are raising their only child.

“It was like an explosion in my head,” says Mo, who lives in the eastern port city of Weihai, in Shandong province. “My only thought was, ‘please not my son, please not my son’,” she said, describing her thoughts while searching for her 17-month-old’s health records.

The serial number on his vaccination record matched that of the batch in question, made by one of China’s largest vaccine makers, Changsheng Biotechnology. Mo looked at her son, Congcong, asleep, and felt awful and then angry.

“I thought about all the people involved, from the vaccine company to the regulators. They cannot be called human. They are devils in hell,” she said.

Like Mo, thousands of parents across China have been scrambling for answers this week after revelations their children may have received faulty immunisations under a state-sponsored vaccine program, using products from Changsheng. The incident has sparked one of the country’s largest public outcries in years, one that officials and censors have struggled to contain.

Changsheng, a private company based in Jilin province, is under multiple investigations for fabricating inspection records for a rabies vaccine as well as selling at least 250,000 substandard DPT vaccines – for diphtheria, whooping cough, and tetanus – to health clinics in Shandong. Fifteen people, including the chairwoman of the company, have been arrested on “suspicion of criminal offences” while China’s top graft investigation agency has said it will investigate.

Chinese president Xi Jinping, who rarely comments on such public cases, promised the government would “investigate to the end”. “It is necessary to promptly release the progress of the investigation and effectively respond to the concerns of the people,” he was quoted as saying, according to Chinese state media on Monday.

A recurring issue

There have been no reports of injuries from the defective vaccines and officials promised children would receive new vaccines. But public trust has hit a new low: people say they have heard this all before.

As China has expanded its immunisation program over the past decade, substandard vaccines have been a recurring issue. In 2016, $90m in vaccines were found to be stored improperly in Shandong province. The year before, hundreds of children in Henan province reportedly fell ill after being given out-of-date vaccines. In 2010, a newspaper in Shanxi province reported unrefrigerated vaccines had killed four children.

Many are recalling another public health crisis, in 2008, when tainted milk powder killed six infants and left 300,000 others ill. Officials initially tried to cover up the incident. In the case of Changsheng, inspectors discovered the substandard vaccines last year, but they were not pulled until this month.

Chinese President Xi Jinping has described the country’s latest vaccine scandal as “appalling”, pledging a thorough investigation into China’s worst public health crisis in years.

Taking time out from his trip to Africa, Xi said China was determined to clean up the scandal-ridden industry, ordering local authorities to conduct an investigation immediately and release the findings to the public “on time” to ensure social stability.

“The violations by Changchun Changsheng Bio-technology are serious and appalling,” state broadcaster CCTV quoted Xi as saying, as police in Changchun took the company’s chairwoman Gao Junfang and four senior executives away for questioning.

Xi also ordered the authorities to use severe punishment “to cure the chronic disease [of corruption] and scratch poison from one’s bones”.

He told the authorities to resolutely “improve the supervision of vaccines and guard the bottom line of safety in order to safeguard public interest and social security”.

The orders echoed zero-tolerance directives by Chinese Premier Li Keqiang on the weekend in response to revelations that Changsheng Bio-tech had produced inferior DPT (diphtheria, whooping cough and tetanus) vaccines for children as young as three months old.

July 22, 2018

A new vaccine scandal involving Changchun Changsheng, China’s second-largest producer of anti-rabies vaccines, has caused a tsunami of outrage and media coverage in China this week.

China’s State Food and Drug Administration found that the Jilin-based Changchun company did only not produce fake anti-rabies vaccines, but also substandard DPT[diphtheria, pertussis, tetanus] vaccines, Caijing News reports on Weibo.

The news about Changchun’s violations already came out on July 15th, but especially led to a social media storm this weekend after reports leaked online exposing that the same company had already violated production laws as early as October of last year.

It is not the first time China faces serious problems in its vaccine programmes. In November of 2017, over 650,000 faulty – uneffective – vaccines were recalled in Shandong, Hebei and Chongqing.

In 2016, another scandal concerning the distribution of illegal and potentially deadly vaccines also became a major trending topic on Chinese social media.

It is mandatory for children to be vaccinated in line with the China National Immunization Programme.

At time of writing, the hashtag “Changchun Changsheng Counterfeit Vaccines” (#长春长生造假疫苗#) has already received over 49 million views on Weibo.

The current scandal adds to parents’ mistrust of vaccines in China, with thousands of people on Weibo demanding that those responsible for these violations should be given capital punishment.

On the various Weibo accounts of Chinese state media and local authorities, however, a post has been published that asks people to “not let anger and panic spread,” and to trust that “the relevant departments will deal with this issue in a timely manner.”

Various essays and comments threads about the faulty vaccines were no longer visible as of Sunday afternoon. While Beijing News reports that the Changchun vaccines were not used in Beijing, many questions still linger for worried parents in many other parts of the country.

April 18, 2018

Immunization rates in the Federation of Bosnia and Herzegovina are as low as 40% in some areas and continuing to decline, increasing the risk of large disease outbreaks. But, no one knows precisely why.

Growing vaccine hesitancy, misinformation in social media, lack of trust in the health system, a shortage of health workers and supply issues are all suspected reasons for low coverage rates. However, these are mostly assumptions with little evidence.

"Right now our immunization programming is based on a lot of assumptions," says Dr Sanjin Musa, epidemiologist at the Institute for Public Health in Bosnia and Herzegovina. "We need better data to understand which population groups have the lowest coverage and why it is so low."

Using WHO’s Tailoring Immunization Programme (TIP) – a structured research approach – the country is working to identify populations susceptible to vaccine-preventable diseases, diagnose barriers and motivators to vaccination, and recommend evidence-informed responses to improve coverage.

State of immunization

TIP was developed in 2013 by the WHO Regional Office for Europe to assist health care professionals, public health authorities and decision-makers in tailoring services to close gaps in immunization coverage. The first step in the TIP process is for countries to conduct a situational analysis to take stock of data on coverage and outbreaks, gather key stakeholders, and identify knowledge gaps.

In 2016, only 78% of children in Bosnia and Herzegovina received the third does of diphtheria-tetanus-pertussis (DTP)-containing vaccine, 79% received the third dose of polio, and 83% the first dose of measles vaccine – all falling short of global targets of at least 90 to 95%. Vaccination coverage also varies greatly within cantons and cities, and in some areas rates fall between 40-50%.

These low rates put the country’s population at-risk for large disease outbreaks. In the last decade there have been large outbreaks of measles, mumps and rubella, in part due to the disruption of immunization programmes during the war in the early 1990s, but also to vaccine hesitancy.

"With current large measles outbreaks across the Region, including in nearby Italy, Romania and Serbia, the country is constantly on high alert for outbreaks," says Dr Musa. Immunization is free and mandatory in the country, but there are no mechanisms to ensure compliance.

July 17, 2017

Worldwide, 12.9 million infants, nearly 1 in 10, did not receive any vaccinations in 2016, according to the most recent WHO and UNICEF immunization estimates. This means, critically, that these infants missed the first dose of diphtheria-tetanus-pertussis (DTP)-containing vaccine, putting them at serious risk of these potentially fatal diseases.

Additionally, an estimated 6.6 million infants who did receive their first dose of DTP-containing vaccine did not complete the full, three dose DTP immunization series (DTP3) in 2016. Since 2010, the percentage of children who received their full course of routine immunizations has stalled at 86% (116.5 million infants), with no significant changes in any countries or regions during the past year. This falls short of the global immunization coverage target of 90%.

"Most of the children that remain un-immunized are the same ones missed by health systems," says Dr Jean-Marie Okwo-Bele, Director of Immunization, Vaccines and Biologicals at WHO. "These children most likely have also not received any of the other basic health services. If we are to raise the bar on global immunization coverage, health services must reach the unreached. Every contact with the health system must be seen as an opportunity to immunize."

Immunization currently prevents between 2–3 million deaths every year, from diphtheria, tetanus, whooping cough and measles. It is one of the most successful and cost-effective public health interventions.

Global immunization coverage levels

According to the new data, 130 of the 194 WHO Member States have achieved and sustained at least 90% coverage for DTP3 at the national level – one of the targets set out in the Global Vaccine Action Plan.

However, an estimated 10 million additional infants need to be vaccinated in 64 countries, if all countries are to achieve at least 90% coverage. Of these children, 7.3 million live in fragile or humanitarian settings, including countries affected by conflict. 4 million of them also live in just three countries – Afghanistan, Nigeria and Pakistan – where access to routine immunization services is critical to achieving and sustaining polio eradication.

In 2016, eight countries had less than 50% coverage with DTP3 in 2016, including Central African Republic, Chad, Equatorial Guinea, Nigeria, Somalia, South Sudan, Syrian Arab Republic and Ukraine. Globally, 85% of children have been vaccinated with the first dose of measles vaccine by their first birthday through routine health services, and 64% with a second dose. Nevertheless, coverage levels remain well short of those required to prevent outbreaks, avert preventable deaths and achieve regional measles elimination goals.